Table 3.
Analysis reports | N=12 | % |
---|---|---|
S6: Written reports | 10 | 83.3 |
Oral reports | 2 | 16.7 |
S1: Description of the data collection method | 10 | 83.3 |
Individual interviews | 10 | 100.0 |
Collective debriefing | 10 | 100.0 |
Files | 6 | 60.0 |
Area visits | 4 | 40.0 |
S2: Description of the chronology of facts | 9 | 75.0 |
S2: Description of existing recommendations | 3 | 25.0 |
S2: Error identification | 7 | 58.3 |
S3 and S4: Identification of contributing or latent factors | 11 | 91.7 |
Management | 2 | 18.2 |
Organisation and procedures | 11 | 100.0 |
Working environment | 7 | 63.6 |
Teamwork | 7 | 63.6 |
Technical processes | 6 | 54.5 |
Professionals | 4 | 36.4 |
Patients | 3 | 27.3 |
Corrective actions | ||
S5: Proposed actions | N=23 | |
Staff training | 6 | 26.1 |
Writing procedures | 8 | 34.8 |
Organisational changes | 5 | 21.7 |
Increasing resource materials | 4 | 17.4 |
Decided actions | N=14 | |
With a professional in charge | 8 | 57.1 |
From the ED | 7 | 87.5 |
From another department | 1 | 12.5 |
With a defined deadline | 6 | 42.9 |
ED, emergency department.